Hospital variation in episiotomy use and the risk of perineal trauma during childbirth

Lidocaine spray vs mepivacaine local infiltration for suturing 1st/2nd grade perineal lacerations: a randomised controlled non-inferiority trial

BACKGROUND

Perineal lacerations are a very common complication of post-partum. Usually, the repair of 1st and 2nd-grade lacerations is performed after the administration of local anesthesia. Despite the great relevance of the problem, there are only a few studies about the best choice of local anesthetic to use during suturing. We performed a randomised controlled trial to evaluate the efficacy and safety of the use of a local anesthetic spray during the suturing of perineal lacerations in the post-partum.

METHODS

We compared the spray with the standard technique, which involves the infiltration of lacerated tissues, using the NRS scale. 136 eligible women who had given birth at University Hospital of Udine were enrolled and randomly assigned to receive nebulization of Lidocaine hydrochloride 10% spray (experimental group) or subcutaneous/submucosal infiltration of mepivacaine hydrochloride (control group) during suturing of perineal laceration.

RESULTS

The lacerations included 84 1st-grade perineal traumas (61.7%) and 52 2nd-grade perineal traumas (38.2%). All the procedures were successfully completed without severe complications or serious adverse reactions. There were no statistically significant differences between the two groups in terms of blood losses or total procedure time. Moreover, there were no statistically significant differences in terms of NRS to none of the intervals considered. Regarding the application of the spray in the B group, in 36 cases (52.9%) it was necessary to improve the number of puffs previously supposed to be sufficient (5 puffs). Just in 3 cases, an additional injection was necessary (4.4%).

CONCLUSIONS

Our study demonstrates that lidocaine spray alone can be used as a first line of local anesthetic during the closure of I-II-grade perineal lacerations, as it has comparable efficacy to mepivacaine infiltration.

TRIAL REGISTRATION

The trial was recorded on https://clinicaltrials.gov . Identification number: NCT05201313. First registration date: 21/01/2022. Unique Protocol ID: 0042698/P/GEN/ARCS.

The influence of the attending midwife on the occurrence of episiotomy: A retrospective cohort study

BACKGROUND

Episiotomy at the time of vaginal birth can result in short- and long-term complications for women. Therefore, it is important to study factors that influence the occurrence of episiotomy.

AIM

To examine to what extent the individual factors of clinical midwives in the same working conditions contribute to variations in episiotomy.

METHODS

A retrospective cohort study was performed at a secondary care hospital in Amsterdam, the Netherlands, using data from women who were assisted by a clinical midwife during birth in 2016. The clinical midwives filled out a questionnaire to determine individual factors. The predictive value of the individual factors of the clinical midwives was examined in a multiple logistic regression model on episiotomy.

RESULTS

A total of 1302 births attended by 27 midwives were included. The mean episiotomy rate was 12.7%, with a range from 3.2% to 30.8% among midwives (p = 0.001). When stratified for parity, within the primipara group there was a significant variation in episiotomy among midwives with a range from 7.9% to 47.8% (p = 0.006). No significant variation was found in the occurrence of third/fourth degree tears or intact perineum. There was a significant difference in episiotomy for maternal indication among midwives (p = 0.041). Predictors for an episiotomy were number of years since graduation and place of bachelor education of the clinical midwife.

CONCLUSION

This study shows that individual factors of clinical midwives influence the rate of episiotomy. Predictors for an episiotomy were the number of years since graduation and place of bachelor education. This shows that continuous training of clinical midwives could contribute to reducing the number of unnecessary episiotomies. Since suspected fetal distress is the only evidence based indication to perform an episiotomy, there is room for improvement given the variation in the number of episiotomies performed for maternal indication.

The Effect of Epidural Analgesia on Labour and Neonatal and Maternal Outcomes in 1, 2a, 3, and 4a Robson's Classes: A Propensity Score-Matched Analysis

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson’s classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs.

Episiotomy practice and associated factors among mothers who gave birth at public health facilities in Metema district, northwest Ethiopia

BACKGROUND

Episiotomy is a surgical incision of the perineum to hasten the delivery. There is a scarce of information related to episiotomy practice, and its associated factors, in developing countries, including Ethiopia. Thus, this study was aimed to determine the level of episiotomy practice and to identify its determinants at public health facilities of Metema district, northwest, Ethiopia.

METHODS

Institutional-based cross sectional study was conducted among 410 delivered mothers from March 1 to April 30, 2020. We recruited study participants using systematic random sampling technique. Data were entered to Epi data version 3.1 and exported to STATA version 14 for statistical analysis. Stepwise backward elimination was applied for variable selection and model fitness was checked using Hosmer and Lemshows statistics test. Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.

RESULTS

In this study, the magnitude of episiotomy practice was found 44.15% (95% CI 39.32-48.97). Vaginal instrumental delivery (AOR 3.04, 95% CI 1.36-6.78), perineal tear (AOR 3.56, 95% CI 1.68-7.55), age between 25 and 35 (AOR 0.11, 95% CI 0.05-0.25), birth spacing less than 2 years (AOR 4.76, 95% CI 2.31-9.83) and use of oxytocin (AOR 2.73, 95% CI 1.19-6.25) were factors significantly associated with episiotomy practice.

CONCLUSIONS

Magnitude of episiotomy practice in this study is higher than the recommended value of World Health Organization (WHO). Instrumental delivery, age, oxytocin, birth spacing and perineal tear were significant factors for episiotomy practice. Thus, specific interventions should be designed to reduce the rate of episiotomy practice. Plain English summary The routine use of episiotomy practice is not recommended by WHO. A study that compares routine episiotomy with restrictive episiotomy suggests that the latter is associated with less posterior perineal trauma, less need for suturing, and fewer complications related to healing. In addition, though, the rate of episiotomy has been declined in developed countries, still it remains high in less industrialized countries. The data for this study were taken at public health facilities of Metema district, northwest, Ethiopia. We included a total of 410 delivered mothers. The magnitude of episiotomy practice was found 44%. This result was higher than the recommended value of WHO. The WHO recommends an episiotomy rate of 10% for all normal deliveries. The result of this study showed that episiotomy practice is common among mothers whose age group are 18-24. In addition, mothers whose labor were assisted by instrumental vaginal delivery are more likely to have episiotomy as compared to those delivered by normal vaginal delivery. Laboring mothers who had used oxytocin were about three times more likely to be exposed for episiotomy than laboring mothers who did not use oxytocin drug. Moreover, episiotomy practice was nearly five times more likely among mothers who had birth spacing of 2 years and less as compared to mothers who had birth spacing of more than 2 years.

A multicenter cross-sectional study of episiotomy practice in Romania

RATIONALE, AIMS, AND OBJECTIVES

The aim of this study was to focus attention on episiotomy practice in Romanian maternity units in order to identify factors associated with the very high rate of the procedure in Romania and to consider strategies to reduce it.

METHODS

In this clustered cross-sectional study, a total of 11 863 patients were recorded in eight Romanian maternity units to assess the prevalence of episiotomy. A random effects Poisson model was used to estimate the prevalence rate in univariate and multivariate models.

RESULTS

Among the 11 863 patients included for analysis, 8475 (71.4%) had an episiotomy. The prevalence of episiotomy was 92.7% for the first vaginal birth, 73.2% for the second vaginal birth, and 35% for the third vaginal birth. The overall rate of suturing was higher than the episiotomy rate for all patients (total rate 79.2%). The likelihood of exiting the maternity ward with an intact perineum after the first vaginal birth was less than 5% at the first vaginal birth.

CONCLUSIONS

In conclusion, routine episiotomy is the norm in Romanian maternity units, with episiotomy rates among the highest in Europe. Episiotomy use is mainly driven by local professional norms, experiences, previous training, and practitioners' decisions rather than evidence, guidelines, or variations in patient needs at the time of vaginal birth.

Episiotomy and the development of postpartum dyspareunia and anal incontinence in nulliparous females

OBJECTIVE

The impacts of an episiotomy on a woman's sex life and ability to relax the pelvic musculature remain largely unknown. The aim of the present study was to assess the impact of an episiotomy on the development of postpartum dyspareunia and anal incontinence.

MATERIALS AND METHODS

A total of 200 patients participated in the present study. The patients were grouped as follows: vaginal delivery with episiotomy (Group 1, N=100) and Caesarian section (Group 2, N=100). An interview, which asked about the presence of dyspareunia or anal incontinence, was conducted with the participants at 12 weeks postpartum.

RESULTS

The mean age (years) of Group 1 was 22.6±4.4, and the mean age of Group 2 was 24.1±4.6. Anal incontinence was detected in 4 patients (4%) in Group 1 and 2 patients (2%) in Group 2. Dyspareunia was present in 21 patients (21%) in Group 1 and 8 patients (8%) in Group 2. No significant differences were detected in the severity of anal incontinence between the two groups. The amount of time to the first coitus following delivery and the total amount of intercourse was compared between the two groups.

CONCLUSION

It appears that episiotomies do not lead to anal incontinence. However, episiotomies may cause dyspareunia, a condition that may negatively affect a women's sex life. Therefore, routine episiotomies are not suggested.

Provider contribution to an episiotomy risk model

OBJECTIVE

The extent to which the observed variation in episiotomy rates can be attributed to individual practitioners is not known. We sought to analyze the contribution of the attending midwife to a risk model for episiotomy.

STUDY DESIGN

We prospectively collected data on 736 consecutive vaginal deliveries in nulliparas at a tertiary maternity hospital. The study measures the impact of the attending midwife on the decision to perform an episiotomy, controlling for a host of patient and clinical characteristics. Midwife effect is evaluated in terms of its overall contribution to the explanatory power of logistic regression model.

RESULTS

The overall rate of episiotomy in primiparas was 40.6%. Individual midwife episiotomy rate ranged from 5.6% to 73.9% (p < 0.0001). After controlling for confounding factors with logistic regression, maternal age ≥35 years (OR 1.61, 95%CI: 1.02-2.52), vacuum extraction (OR 26.88, 95%CI: 2.57-280.7), fundal pressure (OR 62.90, 95%CI: 18.39-214.98), second-stage duration (OR 2.24, 95%CI: 1.53-3.28), and the individual midwife were all associated with episiotomy use. The midwife attending the birth and fundal pressure provided the greatest explanatory power of the model.

CONCLUSIONS

The attending provider adds a significant independent effect to the episiotomy risk model. This has implications for both practice and research in this clinical area.

Rates and Indicators for Episiotomy in Modern Obstetrics - a study from Saudi Arabia

BACKGROUND

This observational study aimed to describe the rates and indicators for practice of episiotomy during normal labour and to compare them between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above).

METHODS

The study was conducted at Mother and Child Hospital, Buraidah from October- December 2013 as a descriptive cross sectional study.

RESULTS

Overall rate of Episiotomy was 51.20%. Amongst the Primigravidas all went through episiotomies however in G2 and above only 7 patients (4.69%) delivered with episiotomy. Proportions tests revealed that there were significant differences between gravidity groups on two indications of episiotomy (vaginal breech p <0.001 and previous history of perineal tear p < 0.001). G2 and above had episiotomy for breech delivery (1 of 7 = 14.29%) significantly more often than PG participants (0 of 142 = 0.0%). And G2 and above participants experienced episiotomy for previous perineal tear (2 of 7 = 28.5% as compared to none in PG No other significant differences were found on indications of episiotomy.

CONCLUSION

Episiotomy is a very common obstetric intervention (51.20%). The PG experience episiotomy significantly more often than G2 and above women. Efforts should be made to reduce its rates. This can be done by reviewing the indications and rates at repeated intervals and setting guidelines for these indications.

Review of the pandemic (H1N1) 2009 among pregnant Japanese women

Pregnant women are prone to serious complications when they contract influenza, and a considerable number of pregnant women died from the pandemic (H1N1) 2009 worldwide; however, no maternal mortality occurred in Japan during this pandemic. This review explores the reasons why maternal mortality did not occur in Japan. Two studies conducted during and soon after the pandemic (H1N1) 2009 in Japan suggested the following: 40,000-50,000 pregnant Japanese women took antiviral medicines for prophylaxis after close contact with an infected person; 40% of them (16,000-20,000) contracted the novel influenza and accounted for a half of all 30,000-40,000 pregnant patients with the novel influenza; at least 181 of them required hospitalization; and at least 17 of them developed pneumonitis. Hospitalized women had a 2.5 times higher risk of preterm delivery (at <37 weeks) compared with the general population. The two studies suggested that the following may have contributed to the lack of maternal mortality in Japan: (i) more than 60% of candidates were vaccinated within 1.5 months after the availability of a vaccine against the novel virus; (ii) vaccination reduced the infection rate by 89%; (iii) a large number of women took antiviral drugs before symptom onset after close contact with an infected person; and (iv) approximately 90% of hospitalized pregnant patients took antiviral drugs within 48 hours after symptom onset.

No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial

BACKGROUND

The WHO advises against recumbent or supine position for longer periods during labour and birth and states that caregivers should encourage and support the woman to take the position in which she feels most comfortable. It has been suggested that upright positions may improve childbirth outcomes and reduce the risk for instrumental delivery; however RCTs of interventions to encourage upright positions are scarce. The aim of this study was to test, by means of a randomized controlled trial, the hypothesis that the use of a birthing seat during the second stage of labor, for healthy nulliparous women, decreases the number of instrumentally assisted births and may thus counterbalance any increase in perineal trauma and blood loss.

METHODS

A randomized controlled trial in Sweden where 1002 women were randomized to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The primary outcome measurement was the number of instrumental deliveries. Secondary outcome measurements included perineal lacerations, perineal edema, maternal blood loss and hemoglobin. Analysis was by intention to treat.

RESULTS

The main findings of this study were that birth on the birth seat did not reduce the number of instrumental vaginal births, there was an increase in blood loss between 500 ml and 1000 ml in women who gave birth on the seat but no increase in bleeding over 1000 ml and no increase in perineal lacerations or perineal edema.

CONCLUSIONS

The birth seat did not reduce the number of instrumental vaginal births. The study confirmed an increased blood loss 500 ml - 1000 ml but not over 1000 ml for women giving birth on the seat. Giving birth on a birth seat caused no adverse consequences for perineal outcomes and may even be protective against episiotomies.

Up to seven-fold inter-hospital differences in obstetric anal sphincter injury rates- A birth register-based study in Finland

Background

The occurrence of obstetric anal sphincter injuries (OASIS) - which may have serious, long-term effects on affected women, including faecal incontinence, despite primary repair - varies widely between countries and have been chosen one of the indicators for patient safety in Organisation for Economic Cooperation and Development (OECD) countries and in Nordic countries.

Findings

The aim of the study was to assess risks of OASIS among five university teaching hospitals and 14 non-university central hospitals with more than 1,000 deliveries annually during 1997-2007 in Finland. Women with singleton vaginal deliveries divided into two populations consisting of all 168,637 women from five university hospitals and all 255,660 women from non-university hospitals, respectively, derived from population-based register. Primiparous and multiparous women with OASIS (n = 2,448) were compared in terms of possible risk factors to primiparous and multiparous women without OASIS, respectively, using stepwise logistic regression analysis. The occurrences of OASIS varied from 0.7% to 2.1% in primiparous and from 0.1% to 0.3% in multiparous women among the university hospitals. Three-fold inter-hospital differences in OASIS rates did not significantly change after adjustment for patient mix or the use of interventions. In non-university hospitals OASIS rates varied from 0.2% to 1.4% in primiparous and from 0.02% to 0.4% in multiparous women, and the results remained virtually unchanged after adjustment for known risks.

Conclusions

Up to 3.2-fold inter-hospital differences in OASIS risk demonstrates significant differences in the quality of Finnish obstetric care.

The increased incidence of obstetric anal sphincter rupture--an emerging trend in Finland

OBJECTIVE

To describe recent trends in the prevalence and risk factors of obstetric anal sphincter ruptures during between 1997 and 2007 in Finland.

METHOD

We analyzed a population-based register of 514,741 women with singleton vaginal deliveries recorded in the Finnish Medical Birth Register. Primiparous (n=2315) and multiparous women (n=534) with anal rupture compared in terms of possible risk factors to primiparous (n=215,463) and multiparous (n=296,429) women without anal rupture, respectively, using stepwise logistic regression analysis.

RESULTS

The occurrence of anal rupture increased from 0.5% in 1997-1999 to 1.8% in 2006-2007 among primiparous women, and from 0.1% in 1997-2001 to 0.3% in 2006-2007 among multiparous women. Over the study period, the likelihood of women having anal rupture in these groups increased by a factor of 3.28 (95% CI 2.86-3.76) and 2.83 (95% CI 2.19-3.67), respectively, after adjustments for strong associations with many known risks. Changes in population characteristics and in the use of interventions were small, and these did not cause the increased anal rupture rate. The only exception was vacuum-assisted deliveries, which explained about 9% of the rising anal rupture risk.

CONCLUSIONS

The current obstetric practice is not optimal for protecting the perineum and reflects the need to standardise obstetric care.

[Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy]

OBJECTIVE

To compare two policies for episiotomy: restrictive and systematic.

PATIENTS AND METHODS

It is a quasi-randomised comparative study between two French university hospitals with contrasting episiotomy policies: one using it restrictively and the second routinely. Population included 774 nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. A questionnaire was mailed four years after delivery. Sample size was calculated to allow showing a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures were urinary incontinence, anal incontinence, perineal pain and pain during intercourse.

RESULTS

We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, the groups did not differ in the prevalence of urinary incontinence (26% versus 32%), perineal pain (6% versus 8%), or pain during intercourse (18% versus 21%). Anal incontinence was less prevalent in the restrictive group (11% versus 16%). The difference was significant for flatus (8% versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR=1.84, 95 % CI :1.05-3.22).

DISCUSSION AND CONCLUSION

A policy of routine episiotomy does not protect against urinary or anal incontinence four years after first delivery.

Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy

OBJECTIVE

To compare two policies for episiotomy: restrictive and systematic.

DESIGN

Quasi-randomised comparative study.

SETTING

Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely.

POPULATION

Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks.

METHODS

A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power.

MAIN OUTCOME MEASURES

Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse.

RESULTS

We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05-3.22).

CONCLUSIONS

A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.

Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term

OBJECTIVE

The purpose of this study was to identify an appropriate population and a balanced set of maternal and neonatal measures to drive a hospital network obstetric quality improvement program.

STUDY DESIGN

Sutter Health, a large Northern California health care system with>40,000 births annually, served as the site for this project. We chose to focus on the standardized nulliparous patients: term, singleton, and vertex. A multidisciplinary task force evaluated and selected perinatal outcome and process measures. Data from every hospital were collected prospectively electronically and analyzed centrally.

RESULTS

Outcome measures that were selected included term, singleton, and vertex rates of 3rd/4th-degree laceration, cesarean birth, 5-minute Apgar score of <7, and patient satisfaction. The process measures included episiotomy, induction (37-41 weeks), and admittance with cervical dilation of > or =3 cm. Data collection completeness improved each quarter; by the end of 2002, the data collection completeness rate had reached 99.7%. Every measure demonstrated a large variation among our hospitals, which indicates opportunities for improvement.

CONCLUSION

This balanced set of measures for term, singleton, and vertex patients has been straightforward to collect over a large and diverse hospital system and has engaged all participants successfully.

The role of episiotomy in current obstetric practice

This review traces the clinical use of episiotomy from the eighteenth century to the present and explains why the procedure has a restricted function in current practice. The types of episiotomy are described, and the controversies surrounding the sequelae associated with the procedure are explored. The modern indications for episiotomy including the procedure's place at operative vaginal delivery are discussed. Although the role of the episiotomy in modern obstetrics may be limited, the procedure is important in situations involving nonreassuring fetal status, shoulder dystocia, and perhaps operative vaginal delivery. The optimal type of episiotomy, if any, at forceps or vacuum delivery is yet to be determined.